Sunday, August 19, 2012

Interstitial Fluid and Multiple Sclerosis: Conductor of the Homeostatic Orchestra

As part of the continuing series on systemic homeostasis, I have decided to deliver a post that has both a global application as well as a focused and specific target audience.  Although seemingly contradictory, the main message to take away from this post is that the overall implications of the contribution of interstitial fluid are universal and can be applied to any condition (acute or chronic) or pathology.

The choice of the term "conductor" was made intentionally to convey a fundamental understanding that can be imported from our intuitive notion of conductor into the general "biological" perspective:  Despite the presence of finely tuned intruments and classically trained musicians, it is the conductor that mediates the activities of the orchestra with the end objective of achieving pleasant,  seemless, and integrated sound.  Therefore without the "physiological conductor", the biological orchestra is reduced to a conglomerate of subsystems that ultimately underperform and actually contribute to the overall deterioration of the architectural integrity of the Supersystem (human organism).  More importantly, the role of homeostatic "catalyst" indicates that strategic focus in improving the flow of interstitial fluid will have a significant impact on improving the intrinsic physiological environment and health. I will refer to specific non-invasive strategies for systemic enhancement through the promotion of interstitial fluid flow in the follow-up post...but in order to fully grasp the practical aspects, there needs to be a fundamental understanding of the theoretical and conceptual ideas.

Interstitial Fluid:
Interstitial fluid is defined as the fluid found in the intercellular spaces composed of water, amino acids, sugars, fatty acids, coenzymes, hormones, neurotransmitters, salts, and cellular products. It bathes and surrounds the cells of the body, and provides a means of delivering materials to the cells, intercellular communication, and removal of metabolic waste.  In addition to these essential systemic functions, the interstitial fluid also transports nutrients to all of the tissues in the body and has a critical role in tissue maintenance.  It has also been shown that interstitial fluid flows have a role in tissue morphogenesis, tissue remodelling, inflammation, morphoregulation, and immune cell trafficking (1)

Interstitial flows and their corresponding microenvironments
As shown in the adjacent image, interstitial fluid is exists within a matrtix (extracellular matrix, or ECM) that is composed of specialized cells (fibroblasts, etc),  fibers (collagen, elastin), and other differentiated tissues.  The cells are attached to the ECM in a 3-dimensional manner by the specialized fibers and therefore compose a highly active and reactive environment (respond to mechanical stress).

Interstitial flow through the ECM
The flow of blood (within the red vessel) and the flow of lymph (green vessel) can be considered as luminal flow.  The green arrows  represent interstitial / intervascular flows which act upon the ECM through sheer stress and therefore, depending on flow rate and velocity, contribute to the establishment of mechanical stability through mechanotransduction and systemic competence.

Importance of Interstitial Flow Rate:
With the fundamental relevance of interstitial fluid well established, the efficiency of flow velocity and rate become quite obvious.  More specifically, the reduction of interstitial flow rate results in degeneration of the tissue environment (mechanical and systemic).  Further, the flow of interstitial fluid (convection) is typically generated by the pressure gradient that exists between blood and lymph capillaries (see image, red and green tubes respectively) (2), as well as by the mechanical stimulus generated by active muscular contraction.

Relevance to Multiple Sclerosis:
The individual with Multiple Sclerosis manifests a very diverse range of symptomatic challenges which ultimately stress the ability to establish and maintain systemic homeostasis.  Regardless of the specific neurological genesis, the biomechanical manifestations are significant and demonstrate progressive deterioration over time.  They can be demonstrated in the more intuitive fashion such as gait difficulties and dysfunction, postural dysfunction, and spasticity...however, the long-term consequences are more profound.  The select muscular dysfunction ultimately leads to fibrotic conditions brought on and exacerbated by irregular muscular activation, chronic overuse syndromes, and gradual deterioration of the entire extended fascial (connective tissue) system. This can also be described as a loss of the visco-elastic properties of the fascia, connective tissue, and ECM.  This loss of viscoelasticity in the ECM will ultimately reduce interstitial fluid flow similar to the way (to use an analogy) a hair mat would block the flow of water through a drain.  The denser the hair mat, the more resistance to flow is present.  This flow reduction will ultimately results in metabolic waste build-up and inefficient delivery of nutrients to the tissues.  When this is allowed to persist, it will inevitably accumulate and tax an already sensitive system which contribute to a degenerative "spiral" (reduced systemic competence---reduced muscular performance---irregular muscle activation and force transfer---increased fibrotic environments---further reduced systemic competence---further reduced muscular performance, etc...).  The profound muscular consequences are a result of the reduced viscolelastic properties of the deep fascia and the secretion hyaluronic fluid which permits the efficient "sliding" of muscle bundles (as well as capillaries) between each other.  When this is deficient, the result is poor muscle function and force transmission through the mechanical chain as well as to adjacent synergists.

In summary, when the accurate "biophysical" reality is examined and explored, it exposes some fundamental concerns regarding the "Big Pharma" philosophy of treatment of pathology.  Indeed, when a specific "diseased state" exists a mechanistic (disease fighting) strategy should be considered...however, the over-looked and under-appreciated reality is that there exists a profound organic (promotion of health) opportunity that shows equally (or greater) potential to contribute to a homeostatic state.

Practical Strategies:
The follow-up to this post will focus on the strategic implementation of practical (non-invasive) interventions designed to contribute to the improvement of interstitial fluid flow.  As a result, there will be a "flush" of stagnant interstitial fluid and a subsequent "drag" of fresh and nutrient rich fluid.  In addition, the mechanical stimulus will contribute to the healthy remodelling of weak and dysfunctional tissues and therefore reduce any muscular imbalances that exist.

Using the pre-established analogy:  this paradigm serves to contribute to the potential and performance of the "conductor" of the orchestra.  Even with sub-standard "instruments" and musicians, the overall effect on the "music" will be far greater.   


Sunday, August 12, 2012

Implications of Cervical-Cranial Instability in MS: Links to Cerebral Palsy

I have recently been enlightened as to the many challenges associated with Multiple Sclerosis (MS) as well as to the very complex and diverse manifestations.  Although my professional experience and expertise is more deeply rooted in Cerebral Palsy (CP) and general movement dysfunction, my recent investigations and research over the last few months has resulted in some rather interesting links between CP and MS.  These links are note intuitive and have required some analysis to arrive to, however I feel that they are valid concepts to investigate and examine further.
These links are very specific in nature and center around Chronic Cerebrospinal Venous Insufficiency (CCSVI) as well as the presence of cervical-cranial instability (Atlas instability).  My investigation is on-going and therefore relatively "young", however my understadning of this phenomenon is that this Atlas instability (misalignment) transmits compressive forces to the brainstem which in turn may produce venous occlusion resulting in chord ischemia.  This particular manifestation (cervical-cranial instability / misalignment) is quite common and characteristic in individuals with CP.  They manifest profound connective tissue (fascial) weakness that is global in nature...therefore this weakness in the neck is manifest by significant cranial-cervical connections which are typically characterized by complete loss of head control. In addition to this, CP is also characterized by developmental dysfunction...more specifically disrupted establishment of proper bony alignment of the cranium.  This results in sutural deformities and altered bony alignment.  The skeletal distortions contribute to a profound muscular imbalance which further exacerbates the manifestations of the cervical-cranial weakness.

The most interesting finding in my work in CP is that while the structural defficiency remains in place, motor intelligence is still quite actively engaged.  Therefore, there are a number of "intrinsic compensations" that take place.  To use a term from CP expert, Leonid Blyum:  "The instability at this level can be considered as an intrinsic de-capitation".   One of these compansations is the active engagement of the mouth...more specifically the opening of the mouth.  It is very common to observe CP children with their mouth consistently open.  While there are mal-occlusion issues also involved, the most interesting phenomenon occurs when they actively want to stabilize their head or engage in some dynamic performance: They open their mouth very wide and keep it open.  This can be considered as a mechanical "bypass" through which head stability is achieved.  By contracting certain muscles in the jaw, they can artificially stabilize the head and therefore be able to achieve a "quasi-stable" head position which then allows them to improve tracking and proprioceptive performance. This stability is derived from the activation of muscles on the anterior surface of the face /neck to mechanically lock the posterior neck.  In CP, this compensation is also demonstrated by intermitent tongue-thrusting.  This phenomenon draws very interesting links to MS and the focus on dental dysfunction.  My investigation has also revealed that clenching of the jaw is a common occurence that contributes to constant headache and potentially sleep disturbances.  These are physiological stressors that contribute to further exacerbation of the symptomatic challenges in MS.  Although in MS the jaws are clenched and in CP the jaw is held open, it indicates a very tangible link between the cranial-cervical instability and performance of the jaw.  The specific interventions to improve the stability of the cervical-cranial connection in CP has yielded very tangible and measurable reduction in the compensatory actions of the jaw.

In summary, I am aware that my formulations are quite "raw" and my understanding still needs to be populated by more investigation and discussion with experts in the field...however, there is significant precedent to suggest that a focused approach to the cervical cranial instability (without the use of aggressive / invasive procedures) can have very profound positive contribution to improving venous flow, reduction of prevalence of dental dysfunction and associated challenges, and ultimately contribute to a more stable and manageable condition.  I would like to thank my good friend, Jamie Chalmers for introducing me to the MS world with such drive and passion...and I encourage any and all comments and feedback that will help to contribute to the formulation of non-invasive interventions that can be immediately available for the MS community.  I will be continuing my raw investigations and hopefully will be able to share some productive information / demonstration in the very near future!  Best regards, Gavin.

Systemic Homeostasis And Cerebral Palsy

 This is the beginning if what is likely to be a relatively long series of posts...therefore I will make every attempt to keep it as "digestible" as possible.

The stimulus for this particular focus and direction was derived from two sources: 1)  my recent trip to Chile to work with another amazing group of CP children and their (always entertaining) parents and extended family, and 2) a very informative piece of writing I just read (see the One Giant Leap Facebook page for the article on Pain and Stress) that set in motion a train of thought that can only be integrated by writing it down.   Given that this topic is quite comprehensive, it will be more productive to consider this as a general introductory entry into more detailed discussion and explanation.  More importantly, a clear and concise explanation of the overall context will help to solidify the main message of this post.  My thoughts are still relatively "all over the page" at the moment, but my most productive posts historically come from this type of chaotic beginnings.

The following is a very insightful and accurate definition of Homeostasis:  Although the term homeostasis commonly connotes adjustment to achieve balance, McEwen asserts that homeostasis strictly applies to a limited set of systems concerned with maintaining the essentials of the internal milieu. The maintenance of homeostasis is the control of internal processes truly necessary for life such as thermoregulation, blood gases, acid base, fluid levels, metabolite levels, and blood pressure. McEwen’s strict distinction means that homeostasis does not contribute to adaptation; rather, adaptation protects homeostasis.   

This is quite informative when placed within the context of Cerebral Palsy (CP).  Although the statement may seem intuitive, as with many other things in the CP world it gets lost in the myriad of challenges of everyday life (the CP family) and in the dissected, compartmentalized, and (sometimes) overly simplistic "protocols" provided by some health care systems.  The reality is that addressing the needs of the entire organism is logistically impossible to do with any degree of efficiency.  To be precise, the only way a responsible health care delivery system can work (and thrive) is to provide interventions that address the most common denominator...standardization over customization.   This is not a condemnation of the system itself, rather a comment of the necessary can only be delivered to large numbers of people in this manner.  However, this does not mean that each individual person in "lost" simply dictates that each individual CP family unit needs to acquire a fundamental understanding of the conceptual and theoretical realities of CP.  In other words, the more enlightened and informed the CP unit is, the better they are at navigating the multiple theories, philosophies, and interventions and formulating the most effective rehabilitation strategy possible for them.  

 "Failure to sustain homeostasis is fatal. Generic threats to homeostasis include environmental extremes, extreme physical exertion, depletion of essential resources, abnormal feedback processes, aging and disease. Environmental perturbations can threaten homeostatic regulation at any time. The stress response exists to sustain homeostasis." 

When you consider this very accurate statement, the relevance and importance of systemic homeostasis becomes amplified.  The CP individual is continually under excessive physical exertion (excessive muscular activation), experiences abnormal feedback responses (irregular ground force transmission, proprioceptive dysfunction), and in more severe cases is extremely sensitive to temperature change.  Further, this inability to properly adapt to these challenges creates further complication and barriers to improvement.  Therefore the logical rehabilitative strategy should be driven by comprehensive and progressive development / enhancement of systemic homeostasis.  The overwhelming focus and attention in placed squarely on the "biomechanical manifestations" or in some cases on the (relatively unimportant) "cosmetic / aesthetic" presentations.  Although these concerns are indeed a part of the larger picture, they serve no strategic purpose if systemic homeostasis is allowed to deteriorate.  As presented in the article, there are 3 interdependant systems that contribute to the preservation of homeostasis: neural, endocrine, and immune systems.  Further, "the term for the physiological protective, coordinated, adaptive reaction in the service of homeostasis is allostasis. Allostasis insures that the processes sustaining homeostasis stay within normal range".

To summarize this brief introduction,  the overall philosophy emerges quite clearly with respect to the formulation of effective, permanent, and progressive rehabilitation strategies:  The development, enhancement, and protection of systemic homeostasis is the overwhelming priority in the CP individual.  Again, the biomechanical role is significant...most specifically in it's implications in social and cognitive development (see my previous post on the relationship between physical, social, and cognitive development) but it's relevance is dependant on a relatively stable systemic competence.  Further expansion on this subject will explain the various nuances and specifics of homeostasis in the CP individual and then will examine the various strategies to improve and maintain it.  


Monday, August 6, 2012

One Giant Leap on Facebook

The last few months have shown a very exciting and welcomed jump in "readership" of the One Gian Leap blog...which has generated a different set of challenges and "probelms" do I get all of the relevant information out without putting the audience to sleep?

Therefore, the OGL Facebook page has emerged as a more broader and diverse extension of the blog that covers more topics and also links to other valuable sources of information and knowledge.  It allows for the more efficient "day-to-day" exchange of information and education while keeping the format relatively informal, quick, and digestible.  The OGL blog can be considered as the resource for more in-depth, comprehensive, and detailed explanation and formulation.
However, each source will compliment the other and therefore contribute to the more efficicent delivery of the overall OGL message.  I would encourage anyone and everyone who has read material here on the blog to visit the One Giant Leap Facebook page and "browse" all of the additional information from multiple and diverse sources.

Part of the central mandate of this blog is to deliver intelligent and well-formulated concepts, theories, and practices...and the reality is that these are found in a great many places and come from a great many people...therefore the Facebook format is the most efficient and effective way to deliver them to you and provide you with productive links to informative and productive resources.

If this blog has provided some valuable information, then the Facebook presence will certainly continue the process.  Once there, click LIKE as it provides useful information on the most popular subjects and helps to define the subjects and issues that resonate most.

Cheers and happy reading!